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Rehabilitation in Transverse Myelitis

Article  in  CONTINUUM Lifelong Learning in Neurology · August 2011

DOI: 10.1212/01.CON.0000403797.10612.d3 · Source: PubMed

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 Review Article
Address correspondence to
Dr Cristina L. Sadowsky,
Kennedy Krieger Institute,
707 North Broadway, Suite
518, Baltimore, MD 21205,
sadowsky@kennedykrieger.org.
Relationship Disclosure:
Drs Sadowsky and
Bosques report no
disclosures. Dr Becker has
received compensation for
expert witness testimony
and plans to continue to
be available for litigation
consultation. Dr Becker
has also received a grant
from the Bryon Riesch
Paralysis Foundation for a
clinical trial. Ms Dean has
received an honorarium
for a speaking
engagement at the Rare
Neuroimmunologic
Disorders CME
Conference. Dr McDonald
may receive a potential
royalty related to a patent
licensed through
Washington University
School of Medicine from
Restorative Therapies, Inc.
Dr Recio has received
grants from the US
Department of Defense.
Dr Frohman has received
personal compensation for
speaking engagements or
consulting activities from
Abbott Laboratories,
Acorda Therapeutics,
Bayer, Biogen Idec,
Novartis, and Teva
Neuroscience.
Unlabeled Use of
Products/Investigational
Use Disclosure:
Dr Sadowsky discusses
the use of activity-based
restorative therapy and
functional electrical
stimulation for neural
restoration. Drs Becker,
Bosques, McDonald,
Recio, and Frohman and
Ms Dean report no
disclosures.
Copyright*2011,
American Academy of
Neurology. All rights
reserved.
816 www.aan.com/continuum
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Rehabilitation in
Transverse Myelitis
Cristina L. Sadowsky, MD; Daniel Becker, MD;
Glendaliz Bosques, MD, FAAPMR; Janet M. Dean, MS, RN, CPNP, CRRN;
John W. McDonald III, MD, PhD; Albert Recio, MD, RPT, PTRP;
Elliot M. Frohman, MD, PhD, FAAN
ABSTRACT
The consequences of neurologic injuries related to transverse myelitis (TM) are long-
lasting and require rehabilitative interventions in about two-thirds of cases. Because
numerous neural repair mechanisms are dependent on maintenance of an optimal
amount of activity both above and below the injury level, rehabilitation and exercise are
useful not only for compensatory functional purposes but also as tools in neural system
restoration. The application of established neurophysiologic principles to post-TM reha-
bilitation has substantial impact on optimizing residual functional capabilities while
facilitating the processes of central plasticity and reorganization of sensory and motor
programming. The process of neurorehabilitation thereby serves both to treat the pa-
tient with TM and to help physicians interrogate and dissect the mechanisms involved
in spinal cord injury, neuroprotection, and, ultimately, recovery. Post-TM rehabilitation
is lifelong and should be integrated into daily living in a home setting as part of the
global management of paralysis, a chronic condition with significant comorbidities.
Continuum Lifelong Learning Neurol 2011;17(4):816–830.
tage for a given individual (resulting
INTRODUCTION
from an impairment or disability) that
In medicine, rehabilitation is defined as
limits or prevents the fulfillment of a
the process of assisting someone to im-
role that is normal for that individual,
prove or recover lost function after an
depending on age, sex, and social and
event, illness, or injury that has caused
cultural factors.1
functional limitations. The goal of reha-
With such a broad spectrum of ap-
bilitation is usually to restore the lost
plication, rehabilitation of a neurologic
function or return it to a level as close as
injury and its consequences should
possible to the one exhibited prior to
the injury. Thus, the definition of reha- focus on restoration of both physiologic
bilitation is closely related to function. (impairment) and day-to-day (disability)
Function is described according to function. While ability-restoring reha-
the model in which it is studied. Im- bilitation (or habilitation when the
pairment is any loss or abnormality of process addresses function potentially
psychological, physiologic, or anatomi- lost from a disease that strikes a child
cal structure or function. Disability is a during development, before he or she
restriction or lack of ability to perform had a chance to acquire such function)
an activity in the manner or within the has long been recognized by the
range considered normal for a human current medical model, impairment-
being as a result of an impairment. A reversing (re)habilitation is not a con-
handicap is described as a disadvan- cept widely accepted yet. There are
August 2011

several reasons for this, including the
inability to perfectly repair damage
and the lack of correlation between
anatomical and physiologic integrity.
Additionally, the damaged substrate
may be unknown or not ‘‘visible’’ using
current medical assessment tools, mak-
ing it unable to be repaired. In trans-
verse myelitis (TM), all of the above
factors play a role, but rehabilitation ap-
proaches can be expanded to include
concepts of impairment and ability re-
pair and restoration.
TM is defined as a monofocal
inflammatory process of the spinal
cord. It can exist as part of a multifocal
CNS disease (eg, multiple sclerosis,
neuromyelitis optica), a CNS infection
(eg, syphilis, Lyme disease, HIV, human
T-cell lymphotropic virus type I, Myco-
plasma, herpesviruses), a multisystem
disease (eg, systemic lupus erythemato-
sus, sarcoidosis, Sjögren syndrome,
Beh0et disease), or as an isolated idi-
opathic entity. Because of its broad
differential diagnosis, etiology, and prog-
nosis, rehabilitation must be tailored
to the specific setting in which TM oc-
curred. Age at onset should also be
taken into account. This article focuses
on idiopathic TM.
Long-term follow-up data on patients
with TM reveal that approximately one-
third of patients recover with little to
no sequelae, one-third are left with a
moderate degree of permanent disabil-
ity (eg, mild spasticity but independent
ambulation, urgency and/or consti-
pation, some sensory deficits), and
one-third have severe disabilities (eg,
inability to walk or severe gait distur-
bance, absence of sphincter control,
sensory deficits).2,3 It is extremely dif-
ficult to predict at onset into which
category a patient will fall. Certain
surrogate markers have been identified
to guide this prediction. For example,
acute illness requiring ventilator assis-
tance is re lated to later impairment in
Continuum Lifelong Learning Neurol 2011;17(4):816–830
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
KEY POINTS
ambulation. A greater number of white h Rehabilitation of a
blood cells in CSF predicts worse func- neurologic injury and its
tional mobility, as does age younger consequences should
than 3 at onset of disease.4 A high CSF focus on restoration of
interleukin (IL)-6 level in TM predicts both physiologic
acute and long-term disability.5 Virtually (impairment) and
all patients with acute TM require day-to-day (disability)
acute rehabilitation. Based on the data function.
referenced above, it can be concluded h Approximately one-third
that approximately 66% of all patients of patients with
with TM will also require long-term transverse myelitis
rehabilitation. recover with little to no
sequelae, one-third are
left with a moderate
TRADITIONAL REHABILITATION degree of permanent
IN TRANSVERSE MYELITIS disability, and one-third
have severe disabilities.
Functional goals for ‘‘traditional’’ TM re-
habilitation (the rehabilitation con- h Functional goals for
‘‘traditional’’ transverse
cerned with restoring abilities) include
myelitis rehabilitation
maximizing physical independence, ca-
include maximizing
pabilities, and potential. An interdisci- physical independence,
plinary team approach is used, and the capabilities, and potential.
team leadership varies according to the This type of rehabilitation
goal or task (ie, if the goal is gait train- uses an interdisciplinary
ing, the physical therapist is the leader, team approach.
with the physician supporting for medi-
cal management of tone and spasticity
as needed). The rehabilitation team tra-
ditionally includes physicians, thera-
pists, nurses, case managers, and family
members and may also include home
health aides, psychologists, respiratory
therapists, speech-language pathologists,
and orthotists, depending on specific pa-
tient needs and rehabilitation goals.
Physical and occupational therapists
train patients with TM to increase their
strength and joint range of motion
(ROM), improve tone, mitigate pain,
and maximize functional mobility.
Equipment evaluation should be a reg-
ular and systematic feature of neuro-
rehabilitation to determine whether
any equipment changes or modifica-
tions will augment and optimize func-
tional performance. A thorough home
rehabilitation program is developed to
facilitate the patient’s mobility gains in
the home setting and complement the
www.aan.com/continuum 817
 Rehabilitation

KEY POINTS
h Some muscle tightness
may be desirable in
specific locations,
such as tightness of the
finger flexors to produce
strong tenodesis grasp
in an individual with C6
tetraplegia or tightness
of back extensors to
assist triceps paralysis to
regain upright sitting.
h A strength-training
regimen may include
static or dynamic
training performed
through isometric,
isotonic, and isokinetic
techniques, according
to the targeted goal and
the degree of
neurologic deficit and
adapted specifically for
each individual with
paralysis.
training done at the therapy site. The
patient and caregiver are educated on
the home program and expectations
upon hospital discharge.
Achieving adequate joint ROM is
necessary and is facilitated through
stretching exercises, use of appropriate
orthoses, and strengthening exercises.
The most common limitations in move-
ment due to contractures in traumatic
and nontraumatic spinal cord disease
(SCD) involve shoulder external rota-
tion, shoulder elevation, scapular de-
pression, scapular retraction, elbow
extension and supination, hip exten-
sion, ankle dorsiflexion, and great toe
flexion. Some muscle tightness may be
desirable in specific locations, such
as tightness of the finger flexors to
produce strong tenodesis grasp in an
individual with C6 tetraplegia, thereby
resulting in good wrist extension func-
tion, or tightness of back extensors to
assist triceps paralysis and to regain
upright sitting. A limited amount of
overstretching can likewise help in
specific areas, such as the increased
hip external rotation required to put
on socks and shoes. Aggressive ROM
exercises are contraindicated or should
be done with caution in the presence of
unstable fractures, active heterotopic
ossification, deep vein thrombosis, and
osteoporosis. Daily stretching of mus-
cles with terminal sustained stretch is
considered first-line rehabilitative treat-
ment for limitation of motion due to
spasticity.
To target muscle strengthening and
facilitation exercises in individuals with
SCD, all spared or intact muscles are
given progressive resistive exercises,
active-assistive ROM, or active ROM
through the maximum range. Adaptive
muscle changes seen in SCD with exer-
cise training include increased cross-sec-
tional area, predominantly of type II
fibers; increased metabolic capacity due
to increased concentrations of adeno-
sine 5¶-triphosphate and creatine phos-
phate; and increased levels of myofibril-
lar proteins. A strength-training regimen
may include static or dynamic training
performed through isometric, isotonic,
and isokinetic techniques, according to
targeted goals and the degree of neuro-
logic deficit. Training programs using
the DeLorme or Oxford6 methods are
adapted specifically for individuals with
paralysis.
Training activities done on an adjust-
able therapy mat are often composed of
sequenced activities that progress from
the easiest to the most difficult. The
usual progression is from bed mobility
to rolling, prone lying, long sitting,
short sitting, and sitting up from a lying
position. Muscles needed for individ-
uals with lower limb paralysis to be able
to move or position their legs in bed are
wrist extensors, biceps, anterior deltoid,
middle deltoid, and shoulder girdle
stabilizers. Individuals with tetraplegia
are taught to use their arms, head, and
neck for momentum to roll in bed,
keeping the elbow straight while the
shoulder is flexing across the body.
Sitting up from a lying position is a
prerequisite for independent dressing
and transfers. A thorough evaluation
should be conducted to determine the
most appropriate transfer technique for
any individual with paralysis. Depen-
dent transfers include sliding transfers,
the dependent standing pivot tech-
nique, or the use of Hoyer lifts. Trans-
fers that require some active patient
participation include the two-man lift,
the sliding board transfer, or the assis-
ted standing pivot transfer. The goal of
an assisted transfer is to gradually re-
duce the assistance required until the
patient can perform the transfer inde-
pendently. Floor-to-chair transfer train-
ing is very important for anyone who
falls out of a wheelchair or otherwise
ends up on the floor and needs to get
back into a chair.

818 www.aan.com/continuum August 2011

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Ambulation is a commonly ex-
pressed goal of most people with TM.
Patients with injuries at T2 and above
typically cannot achieve ambulation,
whereas patients with T3 to T11 af-
fectation are able to use braces for
physiologic standing and therapeutic
ambulation. The goal for individuals
with a T12 to L2 injury is to achieve
ambulation in the household, while pa-
tients with injuries at L3 and lower are
most likely to achieve ambulation in
the community (distance of more than
150 feet at a time). It should be noted,
however, that patients with T12 to L2
injuries can also achieve community am-
bulation if they are young and highly
motivated.
The attainment of muscle function in
the back and lower extremities helps
physical therapists predict the bracing
needs to aid in ambulation. For ex-
ample, patients with pelvic control and
intact quadratus lumborum and ab-
dominal muscles may walk using long
leg braces (knee-ankle-foot orthoses
[KAFOs]) and crutches. Patients with
some control of muscles crossing the
hip joint, such as iliopsoas, hip adduc-
tors, sartorius, and gluteus maximus,
should be able to walk a limited amount
with long leg braces (KAFOs) and
crutches. Patients with intact quadriceps
can walk full-time with short leg braces
(ankle-foot orthoses [AFOs]). Patients
with intact tibialis anterior and posterior
can walk full-time with short leg braces
(AFOs, supramalleolar orthoses) or no
braces at all.
During the preYgait training pro-
gram, important muscles to strengthen
are core trunk and abdominal muscles,
shoulder depressors and scapula sta-
bilization muscles, and triceps and wrist
extensors. In this phase, a structured
progressive resistive exercise program
for the latissimus dorsi, pectoralis, lower
trapezius, and serratus anterior muscles
is very important to achieve good trunk
Continuum Lifelong Learning Neurol 2011;17(4):816–830
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
KEY POINTS
and hip stability (while the shoulder is h Individuals with an
adducted, the latissimus dorsi can act as injury at the T12 to L2
a hip extensor, given its fixed insertion level can master
and reverse origin, locking the hip in household ambulation,
extension against its own ligaments). while individuals with L3
During gait training, control of the and lower injuries can
pelvis is a critical factor in successful achieve community
ambulation. Gait training includes prac- ambulation.
ticing standing activities between paral- h During a preYgait
lel bars and practicing the gait pattern training program,
inside and outside the bars with assis- important muscles to
tive devices (ie, canes, bilateral fore- strengthen are core
arm or axillary crutches, walkers), over trunk and abdominal
obstacles, on rough terrain or uneven muscles, shoulder
depressors and scapula
ground, on ramps, on curbs, going
stabilization muscles,
through doorways, and when getting
and triceps and wrist
into a car. Training on falling techniques extensors.
includes learning how to fall safely and
h During gait training,
how to get up from the floor. Finally,
control of the pelvis is a
prescribing the appropriate wheelchair
critical factor in
for the level of the deficit, the individu- successful ambulation.
al’s needs and comfort, and any medical-
orthopedic comorbidities is essential.
ACTIVITY-BASED RESTORATIVE
THERAPIES IN TRANSVERSE
MYELITIS
Activity-based restorative therapy (also
known as activity-based therapy or
activity-based rehabilitation) addresses
the impairment and is based on
activity-dependent neural plasticity, in
which changes in the nervous and mus-
cular system are driven by repetitive
activation of the neuromuscular system
above and below the injury level. The
tools of activity-based restorative ther-
apy are the same as those used in tra-
ditional rehabilitation, but the premise
of application is based on the nervous
system’s dependence on activity for
everything from myelination and re-
myelination to new cell birth and syn-
apse formation and, ultimately, to func-
tion. Thus, motor activation (patterned
and nonpatterned) and sensory stimu-
lation as part of the rehabilitation pro-
cess are done with the ultimate goal of
www.aan.com/continuum 819
 Rehabilitation
KEY POINTS
h Activity-based restorative
therapy addresses the
impairment and is based
on activity-dependent
neural plasticity, in
which changes in the
nervous and muscular
system are driven by
repetitive activation of
the neuromuscular
system above and below
the injury level. By using
activity-based restorative
therapy as part of the
rehabilitation process,
the ultimate goal is
neural restoration, not
just function restoration.
h Activity-based restorative
therapy tools are used
to produce motor
activation (patterned
and nonpatterned) and
sensory activation.
h Activity plays a critical
role in development and
neural plasticity,
including influencing
gene expression and
modifying synaptic
strength, synapse
elimination,
myelination,
remyelination, and
axonal growth.
820 www.aan.com/continuum
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
neural restoration, not just function
restoration.
Motor Activation
Patterned motor activation can be done
through both task-specific and nonspe-
cific training.
Task-specific training is easy to un-
derstand and has been practiced since
the beginning of rehabilitation. Loco-
motor training (ie, gait training) is the
best example of patterned, task-specific
training. It can be practiced in a partially
weight-supported environment using
treadmill systems, automatic gait ro-
bots, or water. It can also be practiced
in the traditional overground way.
Two important principles of locomo-
tor training when dealing with neuro-
logic injuries need to be mentioned.
First, maximization of load bearing in
lower extremities is essential, as the in-
crease in load bearing is associated with
an increase in limb EMG activity, and
shared load bearing between upper and
lower extremities decreases EMG activ-
ity in lower limbs.7 Second, optimizing
sensory cues, ensuring normal walk-
ing speed, and optimizing kinematics
(stance/swing, upper extremities pat-
terned swing) play an essential role in
maximizing functional recovery and
minimizing compensation.
Patterned nonspecific training is
based on the principle of neural activa-
tion of the central pattern generator
(CPG). Circuitry for the CPG is located
in the lumbar region of the spinal cord
(L2 to L5).8 Limited input can activate
the CPG and produce interlimb CPG
activation.8,9 Nonspecific patterned
training is accomplished most easily by
using functional electrical stimulation
(FES).
FES is postulated to promote periph-
eral and central nervous system repair
following injury. Following complete
spinal cord transection in rats, lower
extremity FES induced an 82% to 86%
increase in cell birth in the lumbar
spinal cord. In this model, FES doubled
the proportion of the newly born cells
expressing markers suggestive of tripo-
tential progenitors. These data suggest
that controlled electrical activation of
the CNS may enhance spontaneous re-
generation after neurologic injuries.10
In another study, electrical stimulation
applied to the cortical pyramids in rats
enhanced synapse formation in the
spinal cord during development and
following corticospinal tract injury.11
Elegant studies have clearly demon-
strated that activation of the CNS is an
important variable influencing the cel-
lular mechanisms associated with re-
generation. In fact, these studies
indicate that cellular regeneration is de-
pendent on activity. The role of activity
may be even more important in con-
ditions in which normal activity is re-
duced, as in TM. Examples of activity
playing a critical role in development
and plasticity include activity-dependent
gene expression, modification of synap-
tic strength, synapse elimination, myeli-
nation and maintenance of myelination,
and axonal growth. The widespread
dependence of development and plas-
ticity in the CNS on neural activity sug-
gests that optimized neural activity
might also be important for regenera-
tion, given the common cellular mecha-
nisms participating in both processes.12
This concept is further supported by
evidence that increased neural activity
enhances multiple components of spon-
taneous regeneration, while decreased
activity inhibits it.13
Activity itself has been associated
with neurotrophin production; thus, it
is conceivable that the elaboration of
neurotrophins after FES activation
below the injury level underlies the
biological basis for neural reorganiza-
tion and functional improvement.14
Proven functional electrical stimula-
tion benefits. Numerous publications
August 2011

have demonstrated the practical ben-
efits of FES in individuals with se-
quelae of traumatic spinal cord injury
(SCI). Some of those benefits include
increased muscle mass, improved
bone density, enhanced cardiovascu-
lar function, improved body composi-
tion (ratio of muscle to fat), improved
bowel function, decreased spasticity,
improved glucose metabolism, and re-
ductions in bladder infection rate. In
addition, electrical stimulation can be
used in combination with other thera-
pies to enhance functional recovery
from SCI. One example is the use of
FES to facilitate gait.15 In a study of 70
patients, Solomonow and colleagues
demonstrated that 14 weeks of FES
walking (3 h/wk) improved total cho-
lesterol, low-density lipoprotein levels,
and hydroxyproline/creatinine ratios
and reduced spasticity in patients with
paraplegia from SCI.16,17 In another
study, after 10 weeks of FES cycling (2
to 3 sessions/wk), 18 subjects with SCI
showed increased lean muscle mass,
improved American Spinal Injury Asso-
ciation motor and sensory scores, and
reductions in serum levels of IL-6, tu-
mor necrosis factor ", and C-reactive
protein (markers for inflammation).
Limited clinical data are available
on the use of FES in demyelinating
disorders such as TM and multiple
sclerosis (MS). A pilot trial of 12
patients with MS who underwent FES
cycling (3 sessions/wk for 2 weeks)
demonstrated improved spasticity but
failed to show improvement in
strength and walking speed.18 Long-
term FES bracing (3 to 12 months) for
footdrop has been shown to increase
strength and walking speed, suggest-
ing that it strengthens activation of
motor cortical areas and their residual
descending connections in patients
with MS.19 A randomized trial of 44
subjects with MS and footdrop who
received FES bracing or exercise for
Continuum Lifelong Learning Neurol 2011;17(4):816–830
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
KEY POINT
18 weeks demonstrated that exercise h Functional electrical
may provide a greater training effect stimulation has shown
on walking speed and endurance than proven benefits in
FES, although the FES group per- individuals with
formed to a significantly higher level sequelae of traumatic
with FES than without for the same spinal cord injury,
outcome measures. Therefore, the including increased
authors recommended studying the muscle mass, improved
combined therapeutic effects of FES bone density, enhanced
and exercise for this patient group.20 cardiovascular function,
improved body
In a recent pilot trial, patients with MS
composition, improved
showed improvement on a broad
bowel function,
array of functional and neurologic decreased spasticity,
outcome measures including gait, improved glucose
upper extremity dexterity, and quality metabolism, and
of life. Furthermore, analysis of CSF reductions in bladder
before FES and 3 months after initiat- infection rate.
ing FES cycling revealed an enhanced
neural repair program (increased CSF
transforming growth factor $3) and a
reduced inflammatory environment
within the CNS (decreased interferon-,,
IL-7, and IL-8).21
Functional electrical stimulation
characteristics in transverse myelitis.
Successful implementation of FES to
result in muscle contractions requires
an intact lower motor neuron. Tradi-
tionally, the FES technology was used
to generate purposeful contractions of
paralyzed muscles. Newer FES tech-
nology, however, is based on applying
low-level electrical currents that acti-
vate the ascending nerve fibers. Sig-
nals enter the spinal cord and are
switched either directly or via inter-
neurons to the lower motor neuron,
which causes the muscle to contract.
The use of FES is related not only to
direct and visible muscle contraction
but also to the effect of neural activa-
tion in the ascending sensory path-
ways and the effect of electrical
current on the histology and biochem-
ical characteristics of the muscle
fibers.22,23 In TM, the lower motor neu-
ron is generally affected at the level of
the inflammation. For that reason,
muscle contractions in response
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 Rehabilitation

KEY POINT
h Functional electrical
stimulation does not
always produce visible
activation of muscles in
transverse myelitis
because of lower motor
neuron involvement. In
those cases, use of
different current
characteristics
(ie, longer pulse width,
bidirectional/rectangular,
or even direct current)
can prevent muscle
atrophy and its sequelae.
to FES from levels at the injury site are
usually limited or absent. This may be a
transient phenomenon related to the
acute inflammation. In most patients,
some of the lower motor neuron func-
tion returns weeks to months following
the injury. During that period, it is im-
portant to try to avoid muscle atrophy
and its sequelae at that level. This may
be attempted by using other electrical
stimulation devices that utilize an un-
usually long duration (ie, 200 6s) and
unusually shaped (bidirectional, rectan-
gular) current impulse or by activating
the muscle from a different spinal level
in addition to using traditional rehabili-
tation approaches (eg, bracing, taping,
splinting).
Sensory Stimulation
Sensory stimulation can be used to ac-
tivate afferent pathways with the goal of
providing information that can subse-
quently be used to perform a motor task
with the direct effect being improved
motor and sensory function.24,25 An ex-
ample of this is sensory stimulation that
enhances excitatory inflow from muscle
spindles to the motor neuron pools and
depresses the inhibitory effect of the
Golgi tendon organ. Focal sensory ac-
tivation or stimulation and nonfocal
activation (eg, epidural stimulation or
intrathecal delivery of neurotrophin-3
or brain-derived neurotrophic factor)
can also produce complex lower limb
cyclinglike movements. In a double-
blind, randomized controlled clinical
trial using whole-body vibration in
patients with MS, Schuhfried and col-
leagues demonstrated improved pos-
tural control and walking speed.26
PEDIATRIC CONSIDERATIONS
Approximately 20% of patients with
acute transverse myelitis (ATM) are
younger than 18 years of age.27 Pidcock
and colleagues4 analyzed the largest co-
hort of pediatric patients with ATM
ever published using standardized
functional measures. According to the
study, ATM may have a bimodal distri-
bution of age, with approximately 40%
of patients being younger than 3 years
of age (compared to 10% reported in
previous studies) and another peak in
incidence occurring between the ages
of 5 and 17 years. Most patients had
the greatest impairment during the
acute illness period and reached their
functional nadir 2 days after the onset
of symptoms. Eighty-nine percent of
children had acute muscle weakness,
were limited to bed or a wheelchair for
mobility, or required ventilatory assis-
tance during this stage. Of the patients
who were nonambulatory, 52% were
able to walk at least 30 feet with or
without the help of a walker, while
only 39% of the patients who initially
needed ventilator assistance were able
to do so at the time of follow-up.
In the acute phase, 82% of the pa-
tients experienced bladder dysfunction
requiring catheterization, and 50% of
the patients still required catheteriza-
tion at follow-up.
Regarding functional outcome, most
patients were independent in the skill
areas measured by the Functional Inde-
pendence Measure (FIM) and WeeFIM
(FIM for children) systems: self-care, com-
munication, social cognition, transfers,
and locomotion. However, 33% required
minimal to total assistance for ambula-
tion or using the wheelchair for more
than 160 feet. More than half (54%) of
children required minimal to total assis-
tance for sphincter control, while 36%
required assistance for mobility with
transfers and 27% required assistance
for self-care needs. According to this
study, even though most patients
recover adequate muscle strength and
motor control for ambulation, significant
impairments remain within important
functional domains such as transfers,
self-care needs, and sphincter control.

822 www.aan.com/continuum August 2011

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These limitations present an opportu-
nity for rehabilitation management to
prevent secondary complications and fur-
ther improve function in the long term.
In our clinical practice we have
identified a subgroup of children who
presented with CSF and multilevel MRI
changes consistent with ATM. These
children subsequently recovered most
of the function that was acutely lost,
except for one extremity, either upper
or lower, that was left with persistent
flaccid monoplegia (see Case 6-1). On
physical examination, the affected limb
has generally demonstrated intact sen-
sation but severely decreased motor
function, rapid and severe muscle
atrophy, areflexia, and no muscle con-
traction with trials of electrical stimula-
tion. Because of this unusual outcome,
electrodiagnostic studies have been
completed on all of these children.
Results of these studies have been
consistent with severe motor neuron-
opathy. We postulate that these chil-
dren have had an immunologic or
inflammatory reaction to either the
anterior horn cells or their proximal
nerve roots, resulting in a lower motor
neuron pattern of paralysis. We antici-
pated that these children would dem-
onstrate long-term sequelae similar to
those of children affected with polio-
myelitis or brachial plexus injury,
including asymmetric limb growth,
weakness, joint dislocation or contrac-
ture, scoliosis, and scapular winging or
gait abnormalities.28 Upper extremity
fractures (multiple in several children),
including buckle fractures in the wrists,
have been observed in several children
with plegic upper extremities due to
rapid onset and progression of disuse
or neurogenic osteoporosis. Indeed,
children with affected upper extrem-
ities demonstrated shoulder subluxa-
tion, scapular winging, and mild
scoliosis, and children with lower ex-
tremity involvement demonstrated lax-
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Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ity of the hip, hyperextension at the
knee, poor or absent dorsiflexion, and
plantar flexion at the ankle. Bracing
and splinting have been prescribed to
protect affected joints. During obser-
vation of some of these children for
over 2 years, recovery of motor func-
tion has been poor despite aggressive
outpatient and home rehabilitation
programs including strengthening,
weight-bearing activities, gait training
or fine motor skill remediation, joint
stabilization, and bracing.29 All children
were given trials of FES cycle ergome-
try (either upper or lower extremity).
In general, muscle contraction was not
elicited, and, as sensation was intact,
the children’s tolerance for FES was
poor. Because of poor spontaneous re-
covery of neurologic function, these
children have been evaluated for
nerve, muscle, or tendon transfers in
the hope of improving function or at
least slowing the severe muscle and
bone wasting. Three of our patients in
this subgroup have undergone nerve
transfers. Two have received nerve
transfers with or without grafts to the
biceps muscle with the goal of restor-
ing elbow flexion. One has had a nerve
transfer to the quadriceps with the
goal of improving knee extension.
Currently, the results of these proce-
dures are unknown. Referral for nerve
transfers must be made early in the
course of recovery, as experience with
the neonatal and traumatic nerve
injury populations shows that better
outcomes are achieved if these proce-
dures are performed within 3 to 9
months, as fewer muscle fibers and
less motor endplate atrophy will be
present.30 The goal of muscle and ten-
don transfer procedures is to stabilize
joints (such as the shoulder or ankle)
and to potentially improve function
(such as elbow flexion or ankle plantar
flexion or dorsiflexion). Because these
procedures are not as time-sensitive,
www.aan.com/continuum 823
 Rehabilitation

Case 6-1
A 6-year, 8-month-old boy (Patient 1) presented
with sudden-onset right upper and lower limb
weakness with associated pain and muscle
spasm. A 3-year, 9-month-old girl (Patient 2)
presented with left upper limb weakness
progressing to left lower limb weakness,
pain, and spasms. Acutely, both patients
demonstrated gait disturbance, and neither
lost bowel or bladder function. Both children
reported symptoms of a mild viral illness several
days prior to the onset of paresis. Neither child
had a personal or family history of neurologic
or autoimmune disorders. In both cases, CSF
analysis was consistent with inflammation
(Patient 1 had a white blood cell count of 138, a FIGURE 6-1 T2-weighted axial and sagittal MRI images of
protein of 35 mg/dL, and a glucose of 60 mg/dL; the cervical spine depicting Patient 1 (A) and
Patient 2 (B). A hyperintense T2 signal is present within the
Patient 2 had a white blood cell count of 21, a cervical spinal cord ranging from level C2 through T1 in
protein of 26 mg/dL, and a glucose of 51 mg/dL). Patient 1 and C3 through C7 in Patient 2 (white arrows),
Workup for other causes of myelopathy, corresponding with cervical gray matter areas.
including viral and bacterial cultures, oligoclonal
bands, and serum neuromyelitis optica titers was negative. In both cases, MRI revealed multilevel
cervical T2 changes consistent with spinal cord edema (Figure 6-1). Ultimately, a diagnosis of transverse
myelitis was made in both cases. Patient 1 was treated with antibiotics, antiviral medication, and IV
immunoglobulin. Patient 2 was treated with IV methylprednisolone sodium succinate for 5 days with
taper over 6 weeks. Both recovered full lower extremity motor function within 10 days; however,
unilateral upper extremity paresis persisted.
Subsequent electrodiagnostic studies revealed
evidence of severe motor neuronopathy.
Evaluation of the affected upper extremity 14
months (Patient 1) and 3 months (Patient 2)
after onset demonstrated areflexia at the biceps,
triceps, and brachioradialis muscles with flaccid
tone and severe wasting of proximal and distal
shoulder muscles (Figure 6-2 and Table 6-1).
Sensation was intact and no residual pain was
reported. Significant shoulder subluxation in the
affected limb and upper limb residual paresis
were present in the proximal and distal muscle
FIGURE 6-2 Photographs of Patient 1 (A) and Patient 2 (B)
depicting muscular wasting and disuse
groups with sparing of the finger flexors. Both
atrophy when compared to the unaffected extremity.
children underwent 2 weeks of intensive Glenohumeral subluxation is notable, as is shoulder girdle and
occupational therapy, which included functional trunk asymmetry. Scoliosis is evident in both cases, indicating
electrical stimulation (FES)-assisted upper that the posterior rami are affected.
extremity (UE) ergometry, scapular stabilization
exercises, supported UE weight bearing, and fine motor skill remediation. Mechanical approximation of
the glenohumeral joint was also included, either via FES or supportive bracing. FES-assisted UE
ergometry was performed on the RT300-SA arm cycle, and the deltoids, rotator cuff, biceps, triceps,
finger flexors, and extensors were stimulated sequentially. The children’s tolerance for FES was poor, as
sensation was intact. Alternate exercises were performed with conventional facilitation techniques. A
home therapy program was developed consisting of closed-chain proximal strengthening, fine motor
Continued on page 825

824 www.aan.com/continuum August 2011

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 Continued from page 824
skill remediation,
and mechanical TABLE 6-1 Evaluation Prior to Onset of Rehabilitation
approximation of
the glenohumeral Patient 1 Patient 2
joint, either via FES Physical Examination
or supportive Reflexes Absent Absent
bracing. Both
children continued Muscle bulk Decreased Decreased
with land and Muscle tone Flaccid Flaccid
aquatic therapy at
home twice a week. Pain None None
Patient 1 continued Sensation Intact Intact
with FES-assisted UE
Bowel and bladder Continent Continent
cycling twice a week.
Long-term follow-up Strength (Manual muscle test 0 to 5, 5 indicating full strength)
(20 months for Shoulder flexion 1 0
Patient 1 and 18
Shoulder extension 1 0
months for Patient 2)
demonstrated Shoulder abduction 1 0
persistence of some Shoulder adduction 1 0
UE motor dysfunction
in both patients. Both Shoulder external rotation 1 1
had near-normal Shoulder internal rotation 1 3
finger and wrist
flexion with moderate Elbow flexion 3 0
wrist extension Elbow extension 0 0
strength and had
Forearm supination 1 0
recovered 50% of
active antigravity Forearm pronation 1 0
internal and external Wrist flexion 1 3
rotation at the
shoulder. Patient 1 Wrist extension 1 1
was able to produce Finger DIP extension 2 1
50% of active
Finger DIP flexion 2 4
antigravity shoulder
abduction strength, Finger abduction 0 0
while Patient 2 Finger adduction 0 0
demonstrated 30%
improvement in Opposition 0 1
motor strength
DIP = distal interphalangeal.
output. Because of
slow motor recovery, both children were evaluated for nerve or tendon transfers. Patient 1 was deemed a
candidate for tendon transfers, but the family decided against it. Patient 2 underwent nerve transfers including
spinal accessory nerve to suprascapular nerve and median nerve fascicle to biceps nerve.
Comment. Persistent isolated unilateral UE paresis is a unique complication of transverse myelitis
and is most likely due to injury to anterior horn cells. Restoration of motor function is limited
despite aggressive rehabilitation, and rehabilitation is complicated by intact sensory function. Early
consideration for surgical reconstruction (ie, nerve or tendon transfers) is appropriate.

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 Rehabilitation
they may be delayed to allow for addi-
tional spontaneous recovery.
As in adults, most children with ATM
will require rehabilitative measures to
maximize recovery and manage sec-
ondary complications from the resul-
tant SCI, paralysis, and immobility.
Occupational and physical therapy
should be started as soon as medi-
cally possible to prevent contractures,
muscle atrophy, and skin breakdown.
During the acute stage, therapeutic
modalities should include stretching,
strengthening, and sitting and standing
balance activities. Skilled inpatient and
outpatient physical and occupational
therapy helps to strengthen weak mus-
cles, improve ROM, and minimize de-
conditioning. In the inpatient setting,
the emphasis is on maximizing inde-
pendence with activities of daily living
(ADLs), transfers, and mobility with the
provision and use of appropriate med-
ical equipment (such as wheelchairs,
transfer boards, bathroom equipment,
adaptive equipment, etc.). The patient
should be fitted for braces (resting hand
splints and AFOs) to maintain passive
ROM, if necessary. In the outpatient
setting, the emphasis is on fine motor
skills, proper transfer techniques, and,
if possible, advanced gait training. De-
velopmental milestones should be in-
corporated into the patient’s functional
and rehabilitative goals. Mobility is a
major issue that is addressed initially
and periodically as the patient’s con-
dition changes.
The loss of sensory and motor con-
trol after ATM contributes to a range of
secondary medical complications that
must be prevented or managed to max-
imize the recovery potential. Special at-
tention is required for prevention of
pressure ulcers31 (with adequate posi-
tioning and pressure releases), nutrition-
al inadequacy, metabolic complications
(such as early-onset hypercholesterole-
mia32,33 and obesity34), osteoporosis,
826 www.aan.com/continuum
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
spasticity, deep vein thrombosis, pulmo-
nary embolisms,35 and, in postpubertal
adolescents, neurogenic erectile dysfunc-
tion.36 If not properly managed, venous
thromboembolic events are a common
cause of morbidity and mortality follow-
ing any SCI.35 With high injuries, ability
to control the diaphragm is lost, and
long-term mechanical ventilator assis-
tance for respiratory management is
required. For patients with cervical or
higher thoracic lesions (above T6), au-
tonomic dysreflexia is a life-threatening
potential medical complication.37
In addition, patients develop bladder
and bowel incontinence, commonly
referred to as neurogenic bladder and
bowel. Incontinence can be a source of
embarrassment for older children and
adolescents, and its successful man-
agement necessitates considerable
adherence on their part. To prevent
secondary complications from a neuro-
genic bladder, such as low bladder
compliance, upper tract changes, and
renal deterioration, children should
have renal function monitoring with a
renal ultrasound within the first 3
months of onset, urodynamic testing
within the first 6 months, and early
institution of a clean intermittent cath-
eterization program.38 Monitoring is of
special importance because neurologic
examination or urinary symptoms can-
not accurately predict renal deteriora-
tion. This is important to remember
because the ability to ambulate or the
presence of lower extremity tone does
not correlate with urodynamic find-
ings. The patient’s ability to void vol-
untarily does not mean that bladder
function is normal.38
Muscle spasticity can be a very dif-
ficult problem to manage. The primary
goal is to maintain adequate passive and
active ROM. This is usually achieved by
a daily stretching program and incorpo-
ration of necessary bracing. Splints can
be fabricated for ankles, wrists, elbows,
August 2011

and knees. Sometimes pharmacologic
intervention is required. Oral antispas-
ticity medications can be used for
generalized spasticity. For patients with
local spasticity, chemodenervation pro-
cedures, such as botulinum toxin injec-
tions or phenol blocks, may be of use.
Some children have very difficult-to-
manage spasticity and tone, and addi-
tional interventions, such as intrathecal
baclofen pump implantation, may need
to be considered. The ultimate goal of
these medicorehabilitative interven-
tions is to assist function by relaxing
overpowering spastic muscles and
strengthening weaker muscles, thereby
facilitating specific ADLs. It is essential
to encourage additional activities, espe-
cially aerobic conditioning and an over-
all strengthening program, to aid
development of new skills and recovery
of the CNS.39
As mentioned, younger age of on-
set, specifically under the age of 3
years, has been associated with a
worse outcome.4 In addition to im-
pairments in ADLs and bowel and
bladder control concerns, developmen-
tal implications should be addressed
during the rehabilitative phase in this
patient population. Adequate position-
ing and support are essential because
muscle weakness, spasticity, and lim-
ited weight bearing can lead to mus-
culoskeletal complications such as
scoliosis, rotational (torsional) deform-
ities and hip dysplasia, subluxation, or
dislocation. Nearly all children with
ATM (especially children younger than
5 years of age) will develop scoliosis
if disease onset occurs prior to the
adolescent growth spurt.40 This can
lead to pelvic obliquity, problems with
sitting balance, skin breakdown, and
pain. If scoliosis progresses and be-
comes more severe it may impair
respiratory function because of de-
creased lung volumes and inefficient
diaphragmatic exertion.41It is essential
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Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
KEY POINT
to take full advantage of adequate h In young children with
seating systems, spinal orthoses, and transverse myelitis,
a functional strengthening program to skeletal abnormalities
improve trunk support and sitting (ie, scoliosis, hip
balance. dysplasia) are expected
Bony torsional deformities usually and should be
develop because of muscle weakness aggressively monitored
and abnormal tone. Although experts and corrected.
believe that no amount of splinting,
stretching, torsional cables, or exercise
may reverse these deformities, some
limited studies have demonstrated that
timely use of botulinum toxin injections
combined with a comprehensive reha-
bilitative program may help prevent or
halt the progression in children with
neuromuscular disorders.42
Muscle imbalance, spasticity, con-
tractures, and limited ambulation may
also lead to inadequate acetabular for-
mation, femoral head subluxation, and
dislocation. Problems with hip sublux-
ation or dislocation may occur in up to
82% of children with paralysis from TM,
depending on the age of onset (more
common in younger children) and the
severity of disabilities. Hip ROM, limb
length discrepancies, or ‘‘popping’’
sounds need to be assessed during
regular examination, as these may
result in difficulty with seating, posi-
tioning, transfers, perineal hygiene,
dressing, pressure ulcers, or pain. Ther-
apeutic conservative measures should
include physical therapy and daily
stretching exercises, positioning, weight-
bearing activities, and use of orthotic
devices. A variety of orthotic devices
that attempt to keep the patient’s hip
in an abducted and neutral-to-external-
rotation position are available. This
abduction bracing is contraindicated in
patients who have lower motor neuron
findings, flaccid paralysis, or fixed
deformities. Standing and walking activ-
ities should be encouraged because
these have been shown to delay or
prevent hip subluxation or dislocation in
children.43
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 Rehabilitation
KEY POINT
h Applying conceptually
sound principles of
neural restoration
through rehabilitation
and using rehabilitation
as essential treatment,
rather than as an
afterthought to the
neurologic injury, could
allow for greater
functional gains and
better neural repair.
Exercise and
rehabilitation can be
used as interventions to
facilitate neurorestoration
by applying sound
neurophysiologic
principles rooted in
neural plasticity, cell
birth, myelination/
remyelination, and
synapse formation, all of
them activity dependent.
828 www.aan.com/continuum
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It is essential for the family to be
educated in the impairments that the
patient may experience and in the
provision of a home exercise or therapy
program that they can follow to main-
tain good health and continue to pro-
mote recovery through the years.
Because community reintegration, ad-
vanced education, and functional inde-
pendence have been associated with
higher life satisfaction and better qual-
ity of life,44,45 proactive psychological
interventions can focus on increasing
participation levels. While increasing
functional independence, mobility, so-
cial interaction, and community skills
is important, it is also important to
discuss adulthood transition issues
early in the care of patients with SCI
from TM. Patients and families should
be provided with the necessary tools
for decision making, including com-
munity integration and participation,
in every developmental stage. Activities
that can facilitate skill development
and integration include specialized
camps, adaptive sports, school activ-
ities, sleepovers, and exercise pro-
grams, among others.46
CONCLUSION
This article presented an update con-
cerning rehabilitative interventions in
TM to bring the ‘‘bench’’ concepts to
the bedside. The nervous system is dy-
namic and continually changing, and
maintaining optimal activity is essential
for neural regeneration and restoration.
Complete repair of the damage is not
necessary in order to have adequate
function, and significant changes can
occur even long after the original injury.
Applying conceptually sound princi-
ples of neural restoration through reha-
bilitation and using rehabilitation as
essential treatment, rather than as an
afterthought to the neurologic injury,
could allow for greater functional gains
and better neural repair. Paralysis is a
chronic condition that needs ongoing,
targeted, and well-thought-out inter-
ventions in order to optimize outcomes
and improve function and quality of life.
Studying, applying, and ‘‘dosing’’ exer-
cise and rehabilitative interventions as a
means to repair damage along a treat-
ment paradigm only makes sense. The
treatment paradigm, however, is not
static, but is continuously evolving, es-
pecially with the addition of immune-
modulatory therapy. Because of the
chronic nature of paralysis and its sig-
nificant medical and surgical comorbid-
ities, integrating activity into the daily
home life of individuals affected by SCD
is the only pragmatic approach. Edu-
cation and ongoing reevaluation and
therapeutic changes provided in a medi-
cal center are complemented by home-
based rehabilitative programs designed
to be functional and feasible in the con-
text of daily living and to scientifically
target injured structures. The goal of
rehabilitation is to optimize neurologic
recovery while waiting for a cure for the
damaged spinal cord.
USEFUL WEBSITES
International Center for Spinal Cord
Injuries at Kennedy Krieger Institute
www.spinalcordrecovery.org.
Christopher & Dana Reeve Foundation
NeuroRecovery Network
www.christopherreeve.org/site/c.
ddJFKRNoFiG/b.5399929/k.6F37/
NeuroRecovery_Network.htm.
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